Removal of chest tube thoracostomy (CTT) is a simple procedure, but it is one of the most critical processes in caring of cardiothoracic surgical patients. Removal of CTT is usually indicated when it's function has been fulfilled after cardiothoracic surgery, trauma, or pleural effusions of any reason. The techniques of CTT removal are different, and the optimal technique is yet to be established. Some techniques were slightly touched in the guidelines of the British Thoracic Society and others,,, but it was not touched at all in the just-in-time video of the chest tube presented by the American Association for the Surgery of Trauma - Advanced Trauma Life Support. Securing the chest tube in place during its insertion has been previously described in details., This is to keep the drain in the desired position and to prevent the excessive movement of the drain in and out, and to prevent any spontaneous removal. The current technique of CTT removal after its insertion according to Rashid's technique, has several advantages over the conventional methods,,,,, as seen in the video and described below;
It helps to have safe and simple control over the wound by pulling up the previously placed mattress suture with the dominant hand while removing the tube with the nondominant hand
It does not need placing a new suture to close the wound once the tube is removed
It avoids the use of petroleum gauze that could be a risk for delayed healing
It avoids moisturizing the wound and keeps it dry with a lesser risk of infection
It allows direct inspection of the wound site through the semi-transparent duoderm (hydrocolloid extrathin film) for any signs of infection
It avoids the bulky padding with large amount of dressings and tapes of the wound resulting in unnecessary restriction of chest wall movements that is already jeopardized particularly in trauma patients
It provides perfect wound closure and yields a cosmetic scar
Only one person is enough to perform the procedure safely, thus minimizing the numbers of exposed personnel in case of suspected or confirmed COVID-19.
Clamping a Chest Tube
I never recommend clamping a chest tube except for;
If the tube is accidentally inserted into a liver vein, vena cava, aorta or the heart. This is to stop the patient's exsanguination as a damage control maneuver
During testing the drainage system for air leaks
During changing the bottles of the drainage system
When it is necessary to control the drainage amount as in case of chronic and huge pleural effusions
Temporary clamping in case of autotransfusions if applicable
Prior to insertion in a suspected or confirmed Covid-19 patients.
The author usually takes a chest X-ray after chest tube insertion, before and after its removal as well.
Time to Remove a Chest Tube
When the detected (visually or digitally) air leaks are ceased and the lung is fully expanded with no residual pneumothorax (radiologically confirmed)
When satisfactory 24-h fluid output is obtained. It differs slightly among institutions. However, <200 ml for non-infectious fluids, and <50 ml in empyema during the last 24 h could be used as safe guidelines
No scientific evidence to justify using suction while removing CTT.
COVID-19 Pandemic Impact
We are well aware that CTT is an aerosol-generating procedure with a tube placed into the pleural cavity directly communicating with an injured lung which in turn is the best place housing the coronavirus, so this is an easy way of transmission of the coronavirus to the personnel. Therefore, we strictly follow precautions and guidelines for personal hygiene and correct using personal protection equipment. Furthermore, the following may be necessary;
A viral filter is recommended to be connected to the drainage system when suction is applied
Bleach may be added if indicated to the water seal chamber of the drainage system
For the removal process, only one person is enough to safely perform it with this technique compared to others.
The author acknowledges the assistance of Dr. Mohammad Abdelhay Mahdi Rashid, MD for editing and reviewing the video.